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MSK History
 
 
MSK History
A comprehensive history is the first step to diagnosing patients with conditions such as gout, osteoarthritis, rheumatoid arthritis and connective tissue disorders.
 

Joint Pain

 
 

Overview

  • Pain affecting the hands, wrists, spine, knees or other joints may herald inflammatory or non-inflammatory arthropathy. By assessing certain characteristics of the pain it is possible to distinguish between these two broad groups and focus in on the cause of a patient's symptoms.

Aetiology

    • Causes of Joint Pain

    • Inflammatory

    • Rheumatoid arthritis
    • Seronegative spondyloarthropathies - reactive arthritis, ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease-related arthritis
    • Crystal arthropathies - gout, pseudogout
    • Vasculitis - Wegener’s, polyarteritis nodosa, giant cell arteritis
    • Systemic inflammation - SLE, polymyositis, dermatomyositis
    • Septic arthritis - gonococcal, Staph, Strep, gram negative
    • Other infection - TB, Lyme disease
    • Sarcoidosis
    • Degenerative

    • Osteoarthritis
    • Traumatic

    • Fracture
    • Dislocation
    • Soft tissue injury - menisceal tear, ligamentous tear
    • Haemarthrosis (traumatic or in the setting of coagulopathy)
    • Other

    • Malignancy - sarcoma, metastasis
    • Avascular necrosis
    • Tendonitis
    • Bursitis

History of Presenting Complaint

    • Site

      Number of joints affected; whether the pain is symmetrical or asymmetrical; whether large or small joints are affected.
    • Monoarthralgia: one joint affectedNon-specific; most causes can (initially) present with monoarthralgia
    • Polyarthralgia: multiple joints affectedMore likely to represent an inflammatory cause
    • Symmetrical small-joint involvementSuggestive of rheumatoid arthritis
    • Affecting large joints of the lower limbSuggestive of osteoarthritis or reactive arthritis
    • Pain, swelling and warmth in the great toeClassical presentation of acute gout
    • Onset

      Whether the pain began suddenly or gradually, and in what situation.
    • Sudden onset knee pain and swellingSuggestive of haemarthrosis
    • Onset post traumaSuggestive of fracture, dislocation or soft tissue injury
    • Onset post recent infectionSuggestive of reactive arthritis
    • Character

    • Burning or ‘electric’ painSuggestive of neuropathic pain or fibromyalgia
    • Deep, constant aching painRed flag for malignancy
    • Radiation

      Whether the pain moves anywhere else.
    • Back pain radiating down the arm or legSuggestive of neuropathic pain
    • Associated Symptoms

      Whether the pain is associated with any other symptoms.
    • Joint swellingNon-specific, may be suggestive of inflammation
    • Numbness / paraesthesiaSuggestive of nerve pain
    • FeversSuggestive of septic arthritis or inflammatory cause
    • Eye pain / conjunctivitisSuggestive of reactive arthritis
    • DysuriaSuggestive of reactive arthritis
    • Dry eyes / mouthSuggestive of Sjögren’s syndrome
    • RashPotential SLE or psoriatic arthritis
    • Back pain with bladder or bowel symptomsRed flag for cauda equina syndrome
    • Timing

      How long the pain has been going on for, and whether it is worse at any specific time of day.
    • Constant pain that does not improveRed flag for malignancy
    • Acute attacks of painSuggestive of acute gout
    • Exacerbating Factors

      Whether there is anything that makes the pain worse, such as exercise or prolonged rest.
    • Present at restSuggestive of inflammatory cause
    • Exacerbated with activitySuggestive of non-inflammatory cause e.g. osteoarthritis
    • Back pain worse walking downhillSuggestive of neuropathic pain
    • Alleviating Factors

      Whether there is anything that relieves the pain.
    • Improved with activitySuggestive of inflammatory cause
    • Back pain improved walking uphillSuggestive of neuropathic pain
    • Severity

      How bad the pain is on a scale of 1-10 with 10 being the worst pain, and how the pain is functionally affecting the patient.
    • Hand - buttons, keys, taps, shopping bags, dressing, showering, eating
    • Wrist - dressing, toilet, eating
    • Elbow -  dressing, lifting objects
    • Shoulder - dressing, top shelves, hanging washing, lifting objects
    • Back -  walking, shoes, stairs, hills, lifting
    • Hip - walking, getting in/out of cars, stairs
    • Knee - chairs, shoes, stairs, kneeling, getting in/out of cars
    • Ankle - walking
Last updated on April 19th, 2019
 
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